=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205254083
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOMINIQUE JB BANDARI M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2014
-----------------------------------------------------
Last Update Date | 03/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1815 S. CLINTON AVE STE 360
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-568-8330
-----------------------------------------------------
Fax | 585-568-8327
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1815 S. CLINTON AVE STE 360
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-568-8330
-----------------------------------------------------
Fax | 585-568-8327
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | MD460458
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------